Postoperative Complications

Condition and Etiology	Assessment: Signs and Symptoms	Nursing Care Plan/Implementation
Respiratory Complications—Most Common Are Atelectasis, Pneumonias (Lobar, Bronchial, and Hypostatic), and Pleuritis; Other Complications Are Hemothorax and Pneumothorax
Atelectasis—undetected preoperative upper respiratory infections, aspiration of vomitus: irritation of the tracheobronchial tree with increased secretions of mucus due to intubation and inhalation anesthesia, a history of heavy smoking, or chronic obstructive pulmonary disease; severe postoperative pain, or high abdominal or thoracic surgery, which inhibits deep breathing; and debilitation or old age, which lowers the client’s resistance	Dyspnea; ↑ temperature; absent or diminished breath sounds over affected area, asymmetrical chest expansion, ↑ respirations and pulse rate; tracheal shift to affected side when severe; anxiety and restlessness	Position:unaffected side Turn, cough, and deep breathe; encourage use of inspirometer hourly while awake Postural drainage Nebulization Force fluids if not contraindicated
Pneumonia—see Atelectasis for etiology	Rapid, shallow, painful respirations; crackles; diminished or absent breath sounds; asymmetrical lung expansion; chills and fever, productive cough, rust-colored sputum; and circumoral and nailbed cyanosis	Position of comfort—semi-Fowler’s to high Fowler’s Force fluids to 3,000 mL/day Provide humidification of air and oxygen therapy Oropharyngeal suction prn Assist during coughing Administer antibiotics and analgesics as ordered Diet: high calorie, as tolerated Cautious disposal of secretions; proper oral hygiene Respiratory treatments as ordered
Pleuritis—see Atelectasis for etiology	Knifelike chest pain on inspiration; intercostal tenderness; splinting of chest by client; rapid, shallow respirations; pleural friction rub; ↑ temperature; malaise	Position: affected side to splint the chest Manually splint client’s chest during cough Administer analgesics as ordered
Hemothorax—chest surgery, gunshot or knife wounds, and multiple fractures of chest wall	Chest pain; increased respiratory rate; dyspnea, decreased or absent breath sounds; decreased blood pressure; tachycardia, and mediastinal shift may occur (heart, trachea and esophagus, great vessels are pushed toward unaffected side)	Observe vital signs closely for signs of shock and respiratory distress Assist with thoracentesis (needle aspiration of fluid) Assist with insertion of chest tube to closed-chest drainage (see care of water-seal drainage system, Table 11-5. Review of the Use of Common Tubes and Figure 11-2. Chest Drainage System, Review of the Use of Common Tubes)
Pneumothorax, closed or tension—thoracentesis (needle nicks the lung), rupture of alveoli or bronchi due to accidental injury, and chronic obstructive lung disease	Marked dyspnea, sudden sharp chest pain, subcutaneous emphysema (air in chest wall tissue); cyanosis; tracheal shift to unaffected side; hyperresonance on percussion, decreased or absent breath sounds; increased respiratory rate, tachycardia; asymmetrical chest expansion, feeling of pressure within chest; mediastinal shift—severe dyspnea and cyanosis, deviation of larynx and trachea toward unaffected side, deviation either medially or laterally of apex of heart, decreased blood pressure; distended neck veins; increased pulse and respirations	Remain with client—keep as calm and quiet as possible; STAT chest x-ray Position: high Fowler’s (sitting) Notify physician through another nurse, and have thoracentesis equipment brought to bedside Administer oxygen as necessary Take vital signs to evaluate respiratory and cardiac function Assist with thoracentesis Assist with chest tube insertion and maintenance of closed-chest drainage
Circulatory Complications—Shock, Thrombophlebitis, Pulmonary Embolism, and Disseminated Intravascular Coagulation (DIC)
Shock—hemorrhage, sepsis, decreased cardiac contractility (myocardial infarction, cardiac failure, tamponade), drug sensitivities, transfusion reactions, pulmonary embolism, and emotional reaction to pain or deep fear	Dizziness; fainting; restlessness; anxiety; ↓ LOC BP: ↓ or falling Pulse: weak, thready Respirations: ↑ , shallow Skin: pale, cool, clammy, cyanotic, ↓ temperature; Oliguria CVP <5 cm H₂O; Thirst	Position: foot of bed raised 20 degrees, knees straight, trunk horizontal, head slightly elevated; avoid Trendelenburg’s position Administer blood transfusions, plasma expanders, and intravenous infusions as ordered; medications specific to type of shock. Check: vital signs, CVP, temperature Insert urinary catheter to monitor hourly urine output Administer oxygen as ordered
Deep vein thrombosis (thrombophlebitis)—injury to vein wall by tight leg straps or leg holders during gynecological surgery; hemoconcentration due to dehydration or fluid loss; stasis of blood in extremities due to postoperative circulatory depression; prolonged immobility; placement of catheters (peripherally inserted central catheter [PICC] line, femoral line) that impede venous flow	Calf pain or cramping in affected extremity, redness and swelling (the left leg is affected more frequently than the right); slight fever, chills; Homans’ sign and tenderness over the anteromedial surface of thigh; decreased pulse in affected extremity due to swelling and venous congestion	Maintain complete bedrest, avoiding positions that restrict venous return Apply elastic stockings to prevent swelling and pooling of venous blood Apply warm, moist soaks to area as ordered Administer anticoagulants as ordered Use bed cradle over affected limb Provide active and passive ROM exercises in unaffected limb
Pulmonary embolism—obstruction of a pulmonary artery by a foreign body in bloodstream, usually a blood clot that has been dislodged from its original site	Sudden, severe stabbing chest pain; severe dyspnea; cyanosis; rapid pulse; anxiety and apprehension; pupillary dilation; profuse diaphoresis; loss of consciousness	Administer oxygen and inhalants while client is sitting upright Maintain bedrest and frequent reassurance Administer heparin sodium, as ordered Administer analgesics, such as morphine SO₄, to reduce pain and apprehension
Disseminated Intravascular Coagulation (DIC) (see Physiological Integrity).
Wound Complications—Infection, Dehiscence, and Evisceration
Wound infection—obesity or undernutrition, particularly protein and vitamin deficiencies; decreased antibody production in aged; decreased phagocytosis in newborn; metabolic disorder, such as diabetes mellitus, Cushing’s syndrome, malignancies, and shock; breakdown in aseptic technique	Redness, tenderness, and heat in area of incision; wound drainage; ↑ temperature; ↑ pulse rate.	Assist in cleansing and irrigation of wound and insertion of a drain Give antibiotics as ordered; observe responses
Wound dehiscence and evisceration—obesity and undernutrition, particularly protein and vitamin C deficiencies; immunosuppression; metabolic disorders, cancer; liver disease; common site is midline abdominal incision, frequently about 7 days postoperatively; precipitating factors include: abdominal distention, vomiting, coughing, hiccups, and uncontrolled motor activity	Slow parting of wound edges with a gush of pinkish serous drainage; or rapid parting with coils of intestines escaping onto the abdominal wall; the latter accompanied by pain and often by vomiting. Client reports “giving” sensation.	Position: bedrest, low Fowler’s or horizontal position Notify physician STAT Cover exposed coils of intestines with sterile towels or dressing and keep moist with sterile normal saline Monitor vital signs frequently Remain with client; reassure that physician is coming Prepare for physician’s arrival; set up IV, suction equipment, and nasogastric tube; obtain sterile gown, mask, gloves, towels, and warmed normal saline. Notify surgery that client will be returning to operating room
Urinary Complications—Retention and Infections
Urinary retention—obstruction in bladder or urethra; neurological disease; mechanical trauma as in childbirth or gynecological surgery; psychological conditioning that inhibits voiding in bed; prolonged bedrest; pain with lower abdominal surgery; epidural narcotics	Inability to void within 8 hours postsurgery, despite adequate fluid replacement; palpable bladder, frequent voiding of small amounts of urine or dribbling; suprapubic pain	Assist client to stand, or use bedside commode if not contraindicated Provide privacy Reduce tension, provide support Use warm bedpan Run tap water Place client’s feet in warm water Pour warm water over perineum Catheterize if conservative measures fail
Urinary tract infections—urinary retention, bladder distention, repeated or prolonged catheterization	Urinary: burning and frequency Pain: low back or flank Pyuria, hematuria; ↑ temperature, chills; anorexia; positive urine culture	Push fluids to 3,000 mL daily, unless contraindicated Avoid stimulants such as caffeine Give antibiotics, sulfonamides, or acidifying agents as ordered Give perianal care after each bowel movement
Gastrointestinal Complications—Gastric Distention, Paralytic Ileus, and Intestinal Obstruction
Gastric distention—depressed gastric motility due to sympathoadrenal stress response; idiosyncrasy to drugs: emotions, pain, shock; fluid and electrolyte imbalances	Feeling of fullness, hiccups, overflow vomiting of dark, foul-smelling liquid; severe retention leads to decreased blood pressure (due to pressure on vagus nerve) and other symptoms of shock syndrome	Report signs to physician immediately Insert or assist in insertion of NG tube; attach to intermittent suction Irrigate NG tube with saline (water will deplete electrolytes and result in metabolic alkalosis) Administer IV infusions with electrolytes as ordered
Paralytic ileus—see Gastric distention	Greatly decreased or absent bowel sounds, failure of either gas or feces to be passed by rectum; nausea and vomiting; abdominal tenderness and distention; fever; dehydration	Notify physician Insert or assist with insertion of NG tube; attach to low, intermittent suction Insert rectal tube Administer IV infusion with electrolytes as ordered Irrigate nasogastric tube with saline Assist with insertion of Miller-Abbott tube if indicated Administer medications to increase peristalsis as ordered
Intestinal obstruction—due to poorly functioning anastomosis, hernia, adhesions, fecal impaction	Severe, colicky abdominal pains, mild to severe abdominal distention, nausea and vomiting, anorexia and malaise; fever; lack of bowel movement; electrolyte imbalance; high-pitched tinkling bowel sounds	Assist with insertion of nasoenteric tube and attach to intermittent suction Maintain IV infusions with electrolytes Encourage nasal breathing to avoid air swallowing Check abdomen for distention and bowel sounds every 2 hours Encourage verbalization Plan rest periods for client Administer oral hygiene frequently
Transfusion Reactions—Allergic, Febrile, and Hemolytic
Allergic and febrile reactions—unidentified antigen or antigens in donor blood or transfusion equipment; previous reaction to transfusions; small thrombi; bacteria; lysed red blood cells	Fever to 103°F, may have sudden onset; chills; itching; erythema; urticaria; nausea, vomiting; dyspnea and wheezing, occasionally	Stop transfusion and notify physician Administer antihistamines, as ordered Send STAT urine to laboratory for analysis Institute cooling measures if indicated Maintain strict input and output records Send remaining blood to laboratory for analysis, and order recipient blood sample for analysis
Hemolytic reaction—infusion of incompatible blood (less common, more serious)	Early: chills and fever; throbbing headache, feeling of burning in face; hypotension; tachycardia; chest, back, or flank pain; nausea, vomiting; feeling of doom; later: spontaneous and diffuse bleeding; icterus; oliguria; anuria; hemoglobinuria	Stop infusion immediately; take vital signs and notify physician Send client blood sample and unused blood to laboratory for analysis Send STAT urine to laboratory Save all urine for observation of discoloration Administer parenteral infusions to combat shock, as ordered Administer medications as ordered—diuretics, sodium bicarbonate, hydrocortisone, and vasopressors
Emotional Complications
Emotional disturbances—grief associated with loss of body part or loss of body image; previous emotional problems; decreased sensory and perceptual input; sensory overload; fear and pain; decreased resistance to stress as a result of age, exhaustion, or debilitation	Restlessness, insomnia, depression, hallucinations, delusions, agitation, suicidal thoughts	Report symptoms to physician Encourage verbalization of feelings; give realistic assurance Orient to time and place as necessary Provide safety measures, such as side rails Keep room lit, to reduce incidence of visual hallucinations Administer tranquilizers as ordered. Use restraints as a last resort

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Table 6-9